© 2009 Geoffrey Cowley
On May 15, US President Obama appointed Thomas Frieden as the new Director of his country's principal public health agency, the Centers for Disease Control and Prevention (CDC). His impeccable public health credentials and broad expertise in both infectious and non-communicable diseases make him an ideal choice. However, the agency has recently been through unsettling times, and been plagued with controversy. Frieden has a tough job to restore the CDC to what it once was—the shining star of US federal agencies.
His predecessor, Julie Gerberding, took the helm in a post-9/11 world where a huge priority was to prepare for bioterrorism. She maintained the agency's role in emergency preparedness, expanding and improving response capacity in the face of severe acute respiratory syndrome and other health threats. And she strengthened communication at the CDC, improving the delivery of information to health professionals and the public. However, she also initiated a large reorganisation of the agency, deemed unnecessary by some critics, which damaged morale, and led to the departure of several leading scientific staff. Her actions prompted a letter of concern from five previous CDC Directors on the strategy the agency was adopting. Decision making was highly centralised to her and a small group of loyal staff. She came under fire over the agency's response to hurricane Katrina, supporting the Bush agenda on climate change, and mishandling other health issues. Reports of her putting politics before science dominated her tenure. She resigned in January, 2009.
Under the Bush Administration, the CDC had a low profile in Congress and funding was targeted to only a few programmes. However, the erosion of the public health service predates the Bush period. Today, funding and support are given on a crisis basis, and have resulted in a system with an uneven capacity to protect and promote health across the USA.
Frieden has several immediate priorities to address at the agency. To restore morale, he will need to listen to his staff and constituents, and not be tempted to make any hasty organisational changes without a careful and critical assessment. The CDC needs to reassert its independence from political influence and ensure decision making is more transparent and consultative. The selection and empowerment of Frieden's leadership teams will be vital. Scientific evidence must drive public health policymaking. Already, the credibility of the CDC in the eyes of the new Administration has been enhanced by the effective response during the H1N1 outbreak, and has seen the agency return to its core mission.
Determining the CDC's role in health system reform is a major priority. Little progress can be made in health-care cost containment, improved access, and enhanced quality without public health having a seat and voice at the reform table. With the CDC's focus on cost-effectiveness, population-based interventions, prevention, all within the framework of social justice, the agency has the expertise and knowledge to provide this input, as well as a role in monitoring the impact of reform as it proceeds.
From a disease standpoint, some difficult decisions for Frieden loom over seasonal and novel H1N1 vaccine production and use, as well as addressing the delivery of health care and rapid diagnostics during a pandemic. Absolutely crucial is an increased engagement in chronic disease prevention. In the longer term, traditional public health will need to move from a focus on disease interruption and biomedical interventions to catalysing social change, and providing support for behaviour change—from chronic diseases and obesity to HIV/AIDS.
Other longer-term priorities will include revitalising the discipline of public health, providing more support to state and local health departments, and strengthening global public health surveillance and laboratory capacity. The agency should continue to have a big role in global health, as well as address emerging threats like the health effects of climate change.
The 2010 president's budget for the CDC is US$6·4 billion (an increase of $32 million above the previous year), including an additional amount from the stimulus package for prevention efforts. Frieden will be just what the agency needs if he can be a good spokesperson in Congress and help augment the budget further. As a local health official with the support of a powerful mayor in New York City, Frieden was able to push change quickly and with relatively little political opposition. As CDC Director he will have to be more of a persuader—of Congress, and state and local health officials—who have the real power in making public health policy in the USA. Nonetheless, we are confident he is the right man for this job, and he can take the agency into a new era of leadership both domestically and globally.